Provider Demographics
NPI:1679166243
Name:KIBWAGE, DEBORAH ESTER (NP-C)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ESTER
Last Name:KIBWAGE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DURKEE RD NE STE 49
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37323-6401
Mailing Address - Country:US
Mailing Address - Phone:865-443-5514
Mailing Address - Fax:
Practice Address - Street 1:1508 TOMBRAS AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412-2720
Practice Address - Country:US
Practice Address - Phone:423-867-4969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28929363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner